Another complication of oral surgery is the accidental creation of an opening into the sinus. This may be the result of a root fracture or displacement of a maxillary third molar.
To avoid this complication you should determine from preoperative radiographs if an opening into the sinus is likely (e.g., a solid molar resting against a thin walled large maxillary sinus). When there is a likelihood of such openings, controlled tooth division may be the treatment of choice.
Reacting to an Opening in the Sinus
If you do create an opening into the sinus, the most important step is to place the patient on a sinus regimen consisting of the following:
antibiotics: amoxicillin is a good first choice
nasal spray: Afrin or Neo-synephrine (short term only-prevent rebound effect)
having patient avoid blowing nose and sneeze with mouth open for up to three weeks
This helps keep the sinus free of congestion and possible secondary infections.
Note: If an infection can be avoided, the sinus opening will often close spontaneously. Also, if a secondary procedure is necessary to close the sinus, it is much more likely to be successful if an infection has been avoided.
The patient should be followed and examined weekly to see if closure has occurred (i.e., no reflux of fluids in the nose when drinking or drainage from the opening).
If closure has not occurred in 2 or 3 weeks, a secondary procedure is necessary.
Tuberosity fractures, another complication of oral surgery, are most commonly caused by excessive force during removal of maxillary second and third molars.
When removing teeth the surgeon should keep the tooth and surrounding soft tissues visible at all times and should palpate these areas as pressure is applied. It is important to recognize the fracture immediately, while it is occurring, so that soft tissue and bone can be saved.
Reacting to a Tuberosity Fracture
You should attempt to section the tooth from the fracture segment. If the segment remains attached to periosteum, it should be retained and stabilized with sutures. If you can not separate the tooth from the bony segment, then the overlying soft tissue should be reflected from the bony segment. This is to ensure that the bone and the attached mucosa are not removed with the tooth leaving a large sinus opening that may be difficult to close.
Bleeding, whether primary or secondary, is another complication that can be anticipated and planned for by the surgeon.
Primary bleeding is bleeding associated with the operation. This type of bleeding should present no serious problem.
Secondary bleeding is bleeding that occurs hours or days following a surgical procedure.
The best way to avoid complications is to:
give good postoperative instructions
control the bleeding before the patient is discharged
Reacting to Primary Bleeding
To control primary bleeding use the following:
Procedures for Reacting to Secondary Bleeding
To control secondary bleeding perform the following steps:
Clean the area removing any liver clots that may have formed.
Examine the patient and determine the source of bleeding. (Direct pressure with a
gloved finger to pinpoint the location of the bleeder if it is in the soft tissue.)
Note: You will need good lighting and suction.
Place a moist gauze sponge over the area with pressure for 15 minutes.
If still bleeding, reinject the area with a local anesthetic solution which contains a vasoconstrictor.
If still bleeding, apply one or more sutures as necessary.
If bleeding is from socket, pack the socket.
Request a bleeding workup if bleeding persists or if a coagulation defect is a possibility.
Aspiration/Swallowing of Foreign Objects
Aspiration of foreign material, such as roots, teeth, restorations, sponges, cotton rolls, dentures, drains, etc., occurs and causes obstruction. Practitioners should be constantly aware that they are operating adjacent to the airway and that aspiration and obstruction are constant hazards.
To prevent aspiration or swallowing of a foreign object during oral surgical procedures, a properly placed pharyngeal screen is important. This can usually be done by unfolding a 4 inch by 4 inch gauze and placing it between the surgical area and the posterior pharyngeal area.
If an object is lost in the posterior pharyngeal area, its location (whether it was aspirated or swallowed) must be determined radiographically. In each case, chest and flat plane abdominal radiographs should be ordered.
Reacting to Aspirated Objects
If the object is in the lung, the patient should be referred immediately to the appropriate medical personnel so it can be removed by bronchoscopy or an open thoracotomy to avoid the formation of lung abscess.
Reacting to Swallowed Objects
If the object is swallowed, it should be followed with radiographs to determine its complete passage.
Injury to the inferior alveolar nerve and to the lingual nerve can and do occur with even the best clinicians. Before mandibular impaction surgery or surgery around the mental foramen is done, the possibility of injury to the nerves must be discussed with the patient.
Procedures for Reacting to Nerve Injury
Perform the following steps when reacting to a nerve injury:
Examine the involved area as follows:
Perform a two-point discrimination using calipers.
If there is a disruption of the taste sensation, map out the disruption of tongue for future reference.
Chart the initial extent of the injury as follows:
Draw a picture of the involved area in the chart.
Record or map out the test results on the picture.
If no improvement in 3 to 6 months, consider specialty consultation.
If you do not feel comfortable evaluating the injury, or if you do not see improvement in 3 to 6 months, refer the patient for specialty consultation.
Many patients with TMJ problems state that their first episode of symptoms occurred following a dental extraction, typically of a mandibular tooth.
Dentists should recognize this potential and take the following steps:
Obtain a history of any significant TMJ dysfunction prior to any oral surgical procedure.
Advise patients who have preexisting TMJ dysfunction that an oral surgical procedure may cause additional joint symptoms or damage.
Minimize force placed on the joint and how wide and how long the mouth is opened. (See below.)
Techniques for Minimizing Force
Techniques for minimizing the amount of force placed on the TMJ include:
use of a rubber bite block for any mandibular procedure
use of the least amount of force possible for any mandibular extraction.
Note: It is often appropriate to surgically remove difficult mandibular teeth to minimize the amount of force required. This is particularly important in patients with preexisting TMJ symptoms.
Pain, swelling, and stiffness are expected the first 48 to 72 hours following surgery and are in direct proportion to the severity and length of the procedure accomplished. After 72 hours you should start to see a decrease in these components; if they persist, it is usually a sign of an underlying problem. The patient should then be examined clinically and radiographically.
Redress the socket as necessary. (You may need to redress it several times.)
Note: The dressing should be removed and the patient reevaluated in ten minutes. If the pain does not return, the socket likely does not require redressing.
Treatment for Retention of Root, Bone, or Foreign Body
The extraction site should be examined clinically and radiographically for any extraneous fragments. They may appear within the socket or between the alveolar plate and the mucosa.
Alveolar Plate Fracture Treatment
The socket should be examined for evidence of alveolar plate fracture (i.e., palpate for mobility). Small fragments of bone may need to be removed, but larger ones with periosteal attachment can be left and supportive care given until symptoms resolve.
Treatment for Maxillary Sinus Problems
Persistent pain in maxillary posterior teeth after surgery may be the results of sinusitis. The sinus should be evaluated clinically and radiographically and treated with appropriate antibiotics and surgical intervention when necessary.
Treatment for Pain from Adjacent Teeth
The teeth adjacent to an extraction site should be examined to determine whether the pain is arising from another tooth or associated tissues.